Journal of Human Hypertension

https://doi.org/10.1038/s41371-020-0384-7

ARTICLE

Prevalence and associated factors of undiagnosed hypertension

among women aged 15–49 years in India: an analysis of National
Family Health Survey-4 data
Debjyoti Talukdar1 Mallika Tripathi2 Vrijesh Tripathi
● ●
3 ●
Surujpal Teelucksingh4

Received: 10 February 2020 / Revised: 5 July 2020 / Accepted: 16 July 2020

© The Author(s), under exclusive licence to Springer Nature Limited 2020

Abstract
Hypertension is a major risk factor for cardiovascular disease globally. Although Indian studies have addressed the
prevalence of hypertension and its associated factors, this study focuses upon women in the reproductive age group, 15–49
years, who have undiagnosed hypertension. We use NFHS-4 data for secondary analyses of prevalence and factors
associated with undiagnosed hypertension among women aged 15–49 years in India. Multiple logistic regression was
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undertaken to identify associated factors. Our analyses showed that overall prevalence of undiagnosed hypertension was
18.69% among women aged 15–49 years in India. In rural areas, it was 17.09% compared and 21.73% in urban areas. By
comparison, only 8.86% self-reported a diagnosis of hypertension. Factors associated with undiagnosed hypertension were
age, less than or more than normal BMI, higher wealth quintiles, no education, religion, caste, and geographical zones.
Almost one in five women aged 15–49 years in India has undiagnosed hypertension with implications for personal and
reproductive health.

Introduction
Hypertension is a major risk factor for cardiovascular
disease (CVD) globally [1]. It is well-established that
treatment of elevated blood pressure (BP) results in huge
gains in reducing CVD. According to World Health
Organisation (WHO) estimates, raised BP causes 7.5
million deaths annually and account for 57 million dis-
abilities adjusted life years (DALYs) [2]. The estimated
proportion of DALYs attributed to hypertension in India
has risen from 21 million in 1990 to 39 million in 2016
* Vrijesh Tripathi
Vrijesh.tripathi@sta.uwi.edu
1 if we focus on those screened since nearly half of those
All Saints University School of Medicine, Roseau, Dominica
2
Faculty of Medical Sciences, The University of the West Indies, St
Augustine Campus, St Augustine, Trinidad and Tobago
3
Department of Mathematics and Statistics, Faculty of Science and
Technology, The University of the West Indies, St Augustine
Campus, St Augustine, Trinidad and Tobago
4 being treated while only one-tenth in rural and one-fifth in
Department of Clinical Medical Sciences, Faculty of Medical
Sciences, The University of the West Indies, St Augustine
Campus, St Augustine, Trinidad and Tobago
[3]. The concept of cascade of care, that is, the proportion
with a relevant condition who have been screened, are
aware of their diagnosis, are on medication, and have
achieved control, is an important aspect of assessing the
performance of a health system. Wilber and Barrow first
applied the “rule of halves” to the cascade of care on an
American population in 1972 [4]. The rule of halves states
that half of those hypertensive do not know, half of those
who know are under treatment and half of those under
treatment have their BP under control. Prenissl et al. built
the cascade of care in India measuring the loss of indi-
viduals at each stage of the process on National Family
Health Survey (NFHS-4) data [5]. They found that among
those with hypertension, 76.1% had been screened, 44.7%
were aware of their diagnoses, 13.3% were treated, and
7.9% had achieved control. This rule seems to work well
screened were aware of having elevated BP but the frac-
tions being treated were less than expected. According to
a systematic review conducted by Anchala et al. [6],
among Indians suffering from hypertension, only one-
fourth in rural areas and one-third in urban areas, are
urban areas, have BP under control. In women, treating or
eliminating hypertension has the greatest impact of all

modifiable cardiovascular risk factors [7]. Though
hypertension is traditionally not seen as a woman’s dis-
ease [8, 9], Tyagi et al. found a relationship between
hypertension and postmenopausal status among women
[10]. Our study focused on a much younger population of
women. This population is also susceptible to hyperten-
sion induced by oral contraceptive pills and pregnancy
[11]. Equally, many studies have found equitable rates of
prevalence between men and women in urban settings but
have found the prevalence of hypertension to be greater
among men than women in rural India [12]. The
urban–rural divide is based upon many socio-
demographic and dietary differences such as the rural
households’ lack of regular income, stress on agriculture,
high cost of health care, poverty, malnutrition, dietary
habits and irregular health checkups while the urban
households suffer from poor diets, stress, irregular life-
styles and increased salt intake [8]. This divide implies
that rural households are poorer, uneducated and have
poor access to health care system. The current
study focuses upon women aged 15–49 years in India who
were screened for and diagnosed with hypertension but
were unaware of its existence. The NFHS-4
dataset allows us an opportunity to unravel and define
the scale of this unseen epidemic in urban and rural areas
of India [13].
Methods
Data
The NFHS-4 is a state representative survey conducted by
the Ministry of Health and Family (MoHFW), Government
of India and technically managed by the International
Institute for Population Sciences (IIPS), Mumbai, covering
29 states and 7 union territories of India [13]. As per the
survey conducted and findings of NFHS-4, the cross-
sectional survey was self-weighting at the level of the dis-
trict. It involved two-stage cluster random sampling
approach using population proportionate to size sampling
methodology. Data collection for the survey began on 20
January 2015 and ended on 4 December 2016 [13].
BP was measured using standard apparatus. Consenting
participants were encouraged not to consume any caffei-
nated beverages and restrict alcohol and smoking at least 30
min prior to measurement of BP. They were asked to relax
for at least 5 min and to place their left arm on the table at
the same level of the heart in a resting position. It involved
taking note of first, second, and third systolic and diastolic
readings, respectively at equated time intervals. The mean
of all three readings was taken as the final reading for
our study.
D. Talukdar et al.
Ascertaining hypertension
The sample data were weighted by state, and urban/rural
places of residence, and within major cities for population
differences. A total of 699,686 females within the age group
15–49 years were interviewed. From the database, we dis-
carded data of women who reported that they had been told
that they had high BP (i.e., preexisting/self-reported
hypertension) on two or more occasions by a doctor or
health care professional. These constituted 61,964 (8.86%)
out of the total female population and are presented as
women with self-reported hypertension in Fig. 1. The
missing data under self-reported hypertension (about 11%)
were clubbed with NO self-reported hypertension category
(Fig. 1).
Three systolic readings and three diastolic readings
were recorded by OMRON BP monitor by trained sur-
veyors. We applied the threshold values of 70–270 mmHg
for systolic readings and 40–140 mmHg for diastolic
readings and then calculated the mean of the three read-
ings. Women were then classified as normotensive or
hypertensive according to JNC 7 guidelines in which
systolic readings above 140 or diastolic readings above 90
or both were considered high BP [14]. The JNC 7
guidelines were chosen over the AHA/ACC 2017 criteria
for the following reasons: it has not been proven that the
more stringent criteria viz., 130/80 by AHA/ACC com-
pared with 140/90 set by the JNC 7 are beneficial criteria
for treatment [15, 16] or optimal in Asian populations
[17, 18]. We arrived at a final sample of 112,640 (18.63%)
women respondents with 69,151 (61.39%) living in rural
areas and 43,488 (38.61%) living in urban areas. These
women were those who did not self-report having
hypertension but whose mean BP readings taken during
the survey indicated that they were hypertensive.
Explanatory variables
The characteristics used for analysis of the weighted pre-
valence are as follows: age, smoking history, alcohol con-
sumption, tobacco consumption, wealth index, education,
social caste, religion, BMI, geographical zones, and diet.
The wealth index is a composite measure developed by the
DHS based upon household’s ownership of selected assets,
such as televisions and bicycles; materials used for housing
construction; and types of water access and sanitation
facilities. All 29 states and 7 union territories were divided
into six zones—(1) northern zone comprising Delhi,
Chandigarh, Haryana, Himachal Pradesh, Jammu & Kash-
mir, Punjab, and Rajasthan, (2) central zone comprising
Chhattisgarh, Madhya Pradesh, Uttar Pradesh, and Uttar-
akhand, (3) eastern zone comprising Bihar, Jharkhand,
Odisha, and West Bengal, (4) western zone comprising
Prevalence and associated factors of undiagnosed hypertension among women aged 15–49 years in. . .
Fig. 1 Flowchart showing NFHS-4 data on women aged 15–49 years, deriving the sample for women with undiagnosed hypertension.
Flowchart for undiagnosed hypertension.
Dadra & Nagar Haveli, Daman and Diu, Goa, Gujarat, and
Maharashtra, (5) southern zone comprising Andaman and
Nicobar, Andhra Pradesh, Karnataka, Kerala, Lak-
shadweep, Puducherry, Tamil Nadu, and Telangana, and (6)
north-eastern zone comprising Arunachal Pradesh, Assam,
Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and
Tripura. Diet had seven independent variables such as milk
or curd, pulse or beans, vegetables, fruits, eggs, fish and
chicken or meat. Each of these variables were subdivided
into two categories namely never or occasional and daily or
weekly. See Table 1 for categorizations used for the
variables.
Statistical analyses
Analysis involved weighted data and we calculated overall
prevalence of undiagnosed hypertension and its prevalence in
rural and urban areas. Logistic regression was chosen as the
appropriate statistical tool for analysis. Both unadjusted and
adjusted logistic regression models were analyzed for overall
weighted odds ratio for women aged 15–49 years suffering
from undiagnosed hypertension [19]. The prevalence of
undiagnosed hypertension among various geographical
regions was mapped using open GeoDa software for spatial
data analysis. Local Indicators of Spatial Association (LISA)
is part of GeoDa statistical test, which supplement visualiza-
tion by creating hot & cold spots on the map [20]. All analysis
related to prevalence estimation of undiagnosed hypertension,
body mass index (BMI) and other biomarkers and socio-
demographic profiles were conducted using Stata statistical
software 14.2 (StataCorp LLC) [21].
Results
Prevalence of undiagnosed hypertension
The prevalence of undiagnosed hypertension was 18.63%,
17.09% in rural areas, and 21.73% in urban areas. Table 2
reports the socio-demographic characteristics and weighted
prevalence of undiagnosed hypertension among women
who were found to be hypertensive upon screening of BP.
Age
Age shows a linear relationship with undiagnosed hyperten-
sion among women in rural areas. The relationship was not
linear in urban areas which saw a higher prevalence among
women <25 years of age and above 40 years. The age group
45–49 years showed the highest prevalence of undiagnosed
hypertension of 23.35%, with 22.80% in rural, and 24.49% in
urban areas, respectively. It is to be noted that undiagnosed
hypertension was fairly high even among younger age groups.
Smoking status, alcohol, and tobacco consumption
Weighted prevalence of undiagnosed hypertension was
20.13% among smokers, 24.78% among alcoholics, and
19.73% among tobacco users.
Wealth index
In terms of wealth index, overall prevalence increased
from poorest to richest wealth index. It ranges between
 D. Talukdar et al.

Table 1 List of variables for the

study of undiagnosed
hypertension among women
(15–49 years).
Description and categories
Study variables
Outcome variable Overall hypertension, self-reported hypertension and undiagnosed hypertension
(0 = normal blood pressure; 1 = hypertension)
Explanatory variables
Age Age of participants in years (0 = 15–19; 1 = 20–24; 2 = 25–29; 3 = 30–34;
4 = 35–39; 5 = 40–44; 6 = 45–49)
Current smoking status Smoking habit (0 = nonsmoker; 1 = smoker)
Current alcohol use Alcohol usage (0 = nonalcoholic; 1 = alcoholic)
Current tobacco use Tobacco usage (0 = nontobacco user; 1 = tobacco user)
Wealth Wealth index (0 = Poorest; 1 = Poorer; 2 = Middle; 3 = Richer; 4 = Richest)
Education Education level (0 = no education; 1 = primary; 2 = secondary; 3 = higher)
Social caste Social caste (0 = caste; 1 = scheduled tribe; 2 = no caste/tribe; 3 = do
not know)
Religion Religion (0 = Hindu; 1 = Muslim; 2 = Christian; 3 = others/not stated)
Body mass index (BMI) BMI (0 = normal; 1 = underweight; 2 = pre-obesity;
3 = Obesity Class I; 4 = Obesity Class II; 5 = Obesity Class III)
Zones Zones (0 = Northern; 1 = Central; 2 = Eastern; 3 = Western; 4 = Southern;
5 = North-Eastern)
Diet consumption Diet (never/occasional (N/O) daily/weekly (D/W)
milk/curd (0 = N/O; 1 = D/W); pulse/beans (0 = N/O; 1 = D/W); vegetables (0
= N/O; 1 = D/W); fruits (0 = N/O; 1 = D/W); eggs (0 = N/O; 1 = D/W); fish
(0 = N/O; 1 = D/W);
chicken/meat (0 = N/O; 1 = D/W);

15.72% and 18.92% in rural areas and between 18.55% BMI

and 22.30% in urban areas. It was highest in the “richer”
wealth quintile in both rural and urban areas while being
highest in the “richest” wealth quintile (20.79%) in
overall rates.
Educational attainment
The prevalence of undiagnosed hypertension ranged
between 18.32% and 19.69% in all classifications of the
variable education. In the rural areas, undiagnosed
hypertension was higher among those who had no edu-
cation and those who had higher than secondary education
as compared to those who had studied up to primary or
secondary level only. In the urban areas, it was compar-
able among all levels with the highest prevalence being
among women who had studied up to secondary
level only.
Caste and religion
The prevalence of undiagnosed hypertension ranged from
17.43% among members of no caste/tribe to 18.79% among
those who knew their caste. In terms of religion, 23.08%
followers of the Christian faith were found suffering from
undiagnosed hypertension. The corresponding figures for
followers of the Hindu (18.54%) and Muslim faiths
(18.56%) were lower.
According to BMI classifications, the prevalence was low-
est among those with normal BMI. It was consistently
higher in urban areas as compared to rural areas in all
categories. It was especially higher in urban areas among
underweight (BMI < 18.5) with 28.49% compared to
19.11% in rural areas; and in Obesity class III (BMI ≥ 40)
with 31.09% in urban areas as compared to 21.58% in rural
areas. Majority (27.20%) of women suffering from
undiagnosed hypertension belong to obesity class II (BMI
35–39.9).
Geographical zones
In total, 23.56% of women with undiagnosed hypertension
live in western zone of India comprising the states of
Maharashtra, Gujarat, Goa, Daman and Diu, Dadar and
Nagar Haveli. Among the six zones, undiagnosed hyper-
tension was most prevalent in the rural areas in Telangana
followed by the states of Maharashtra, Karnataka, Kerala,
Tamil Nadu, Andhra Pradesh, Orissa, Meghalaya, Naga-
land, Arunachal Pradesh, Himachal Pradesh, and Delhi
(Fig. 2). Among the urban areas, undiagnosed hypertension
was most prevalent in Maharashtra, Andhra Pradesh, Tel-
angana, and Delhi followed by Himachal Pradesh, Gujarat,
Karnataka, Tamil Nadu, Chhattisgarh, Orissa, Arunachal
Pradesh, Assam, Nagaland, and Mizoram (Fig. 3).
Prevalence and associated factors of undiagnosed hypertension among women aged 15–49 years in. . .

Table 2 Socio-demographic characteristics and Prevalence of undiagnosed hypertension in women (15–49 years).
Characteristics Undiagnosed hypertension Weighted prevalence of undiagnosed hypertension p value
Total (%) Overall (95% CI) Rural (95% CI) Urban (95% CI)

Age: years
15–19 20334 (18.05) 18.15 (17.93, 18.38) 15.34 (15.09, 15.59) 24.81 (24.35, 25.28) 0.000
20–24 19208 (17.05) 17.58 (17.36, 17.81) 15.55 (15.29, 15.81) 21.75 (21.32, 22.18) 0.000
25–29 17081 (15.16) 17.08 (16.85, 17.32) 15.69 (15.41, 15.97) 19.77 (19.35, 20.20) 0.000
30–34 14060 (12.48) 16.89 (16.63, 17.14) 15.80 (15.49, 16.11) 18.96 (18.51, 19.42) 0.000
35–39 14401 (12.79) 18.74 (18.47, 19.02) 18.02 (17.69, 18.36) 20.11 (19.63, 20.60) 0.000
40–44 13755 (12.21) 21.41 (21.09, 21.73) 20.47 (20.08, 20.85) 23.19 (22.64, 23.75) 0.000
45–49 13800 (12.25) 23.35 (23.01, 23.70) 22.80 (22.39, 23.22) 24.49 (23.89, 25.10) 0.000
Current smoking status
Nonsmoker 111095 (98.63) 18.61 (18.51, 18.71) 17. 06 (16.94, 17.17) 21.71 (21.53, 21.90) 0.000
Smoker 1545 (1.37) 20.13 (19.24, 21.04) 19.35 (18.40, 20.34) 23.89 (21.66, 26.28) 0.000
Current alcohol use
Nonalcoholic 110807 (98.37) 18.55 (18.45, 18.65) 16.98 (16.87, 17.10) 21.69 (21.51, 21.88) 0.000
Alcoholic 1832 (1.63) 24.78 (23.81, 25.78) 24.32 (23.25, 25.42) 26.85 (24.55, 29.28) 0.030
Current tobacco use
Nontobacco user 107350 (95.30) 18.58 (18.48, 18.68) 16.99 (16.88, 17.11) 21.71 (21.53, 21.90) 0.000
Tobacco user 5290 (4.70) 19.73 (19.26, 20.21) 18.96 (18.43, 19.50) 22.19 (21.19, 23.23) 0.000
Wealth
Poorest 17989 (15.97) 15.87 (15.66, 16.08) 15.72 (15.51, 15.94) 18.55 (17.57, 19.58) 0.000
Poorer 20575 (18.27) 16.89 (16.68, 17.10) 16.49 (16.27, 16.71) 20.06 (19.39, 20.74) 0.000
Middle 23459 (20.83) 18.80 (18.59, 19.02) 17.85 (17.61, 18.10) 21.60 (21.15, 22.05) 0.000
Richer 25634 (22.76) 20.58 (20.36, 20.81) 18.92 (18.62, 19.23) 22.30 (21.97, 22.63) 0.000
Richest 24982 (22.18) 20.79 (20.56, 21.02) 17.91 (17.50, 18.34) 21.84 (21.57, 22.12) 0.000
Education
No education 30820 (27.36) 18.32 (18.14, 18.51) 17.65 (17.45, 17.85) 21.32 (20.87, 21.78) 0.000
Primary 13661 (12.13) 18.07 (17.80, 18.35) 16.75 (16.44, 17.07) 21.67 (21.11, 22.25) 0.000
Secondary 53422 (47.43) 18.68 (18.53, 18.82) 16.70 (16.53, 16.87) 22.13 (21.88, 22.38) 0.000
Higher 14736 (13.08) 19.69 (19.40, 19.97) 17.57 (17.15, 18.01) 21.10 (20.73, 21.49) 0.000
Social caste
Caste 100176 (89.17) 18.69 (18.59, 18.80) 17.09 (16.96, 17.21) 21.77 (21.58, 21.96) 0.000
Tribe 7507 (6.68) 18.42 (18.04, 18.80) 17.76 (17.36, 18.16) 22.29 (21.25, 23.36) 0.000
No caste/tribe 3886 (3.46) 17.43 (16.94, 17.93) 15.97 (15.37, 16.58) 19.90 (19.06, 20.78) 0.000
Do not know 770 (0.69) 18.79 (17.63, 20.02) 16.01 (14.59, 17.55) 22.56 (20.65, 24.58) 0.000
Religion
Hindu 90190 (80.07) 18.48 (18.37, 18.59) 17.02 (16.90, 17.15) 21.77 (21.56, 21.98) 0.000
Muslim 15428 (13.70) 18.56 (18.30, 18.83) 16.46 (16.12, 16.80) 21.11 (20.70, 21.52) 0.000
Christian 3153 (2.80) 23.08 (22.38, 23.79) 21.96 (21.09, 22.86) 24.90 (23.74, 26.10) 0.000
Others/not stated 3869 (3.43) 19.43 (18.88, 19.98) 18.00 (17.34, 18.68) 21.93 (20.99, 22.90) 0.000
BMI
Underweight (<18.5) 30295 (27.07) 21.28 (21.07, 21.49) 19.11 (18.88, 19.35) 28.49 (28.00, 28.98) 0.000
Normal (18.5–24.9) 57349 (51.24) 16.57 (16.45, 16.69) 15.23 (15.09, 15.38) 19.51 (19.27, 19.75) 0.000
Pre-obesity 17545 (15.68) 20.39 (20.12, 20.66) 20.08 (19.71, 20.45) 20.72 (20.33, 21.11) 0.010
(25–29.9)
Obesity Class I 5099 (4.56) 25.02 (24.43, 25.62) 25.46 (24.54, 26.41) 24.72 (23.95, 25.49) 0.171
(30–34.9)
Obesity Class II (35–39.9) 1158 (1.03) 27.20 (25.88, 28.56) 26.48 (24.27, 28.81) 27.58 (25.95, 29.26) 0.377
 D. Talukdar et al.

Table 2 (continued)
Characteristics Undiagnosed hypertension Weighted prevalence of undiagnosed hypertension p value
Total (%) Overall (95% CI) Rural (95% CI) Urban (95% CI)

Obesity Class III (≥40) 477 (0.43) 26.24 (24.27, 28.32) 21.58 (19.04, 24.35) 31.09 (28.13, 34.21) 0.000
Zones
Northern 12846 (11.40) 17.07 (16.80, 17.34) 14.23 (13.92, 14.55) 21.95 (21.47, 22.44) 0.000
Central 24161 (21.45) 15.38 (15.20, 15.56) 14.53 (14.33, 14.74) 17.68 (17.32, 18.05) 0.022
Eastern 22070 (19.59) 16.30 (16.10, 16.49) 15.82 (15.60, 16.04) 18.01 (17.57, 18.45) 0.000
Western 21055 (18.69) 23.56 (23.28, 22.78) 21.16 (20.80, 21.54) 26.24 (25.82, 26.66) 0.003
Southern 28653 (25.44) 22.55 (22.33, 22.78) 21.97 (21.67, 22.28) 23.32 (22.97, 23.68) 0.000
North-Eastern 3856 (3.42) 18.79 (18.26, 19.33) 18.28 (17.69, 18.87) 20.94 (19.71, 22.24) 0.000
Diet
Milk/curd (N/O) 35717 (31.71) 18.01 (17.85, 18.18) 16.99 (16.80, 17.18) 21.09 (20.74, 21.45) 0.000
Milk/curd (D/W) 76923 (68.29) 18.93 (18.81, 19.05) 17.16 (17.01, 17.30) 21.94 (21.73, 22.15) 0.000
Pulse/beans (N/O) 11331 (10.06) 18.43 (18.12, 18.73) 17.15 (16.81, 17.50) 21.90 (21.28, 22.54) 0.000
Pulse/beans(D/W) 101308 (89.94) 18.65 (18.55, 18.75) 17.09 (16.96, 17.21) 21.71 (21.53, 21.90) 0.000
Vegetables (N/O) 16575 (14.72) 18.36 (18.10, 18.61) 17.09 (16.80, 17.38) 21.46 (20.97, 21.96) 0.000
Vegetables (D/W) 96064 (85.28) 18.68 (18.57, 18.78) 17.09 (16.97, 17.22) 21.77 (21.58, 21.96) 0.000
Fruits (N/O) 59244 (52.60) 17.67 (17.54, 17.80) 16.60 (16.45, 16.74) 21.32 (21.03, 21.61) 0.000
Fruits (D/W) 276117 (56.12) 19.83 (19.68, 19.98) 17.98 (17.79, 18.18) 21.98 (21.75, 22.21) 0.000
Eggs (N/O) 63998 (56.82) 17.70 (17.57, 17.82) 16.30 (16.16, 16.44) 21.03 (20.79, 21.28) 0.000
Eggs (D/W) 48642 (43.18) 20.01 (19.86, 20.17) 18.45 (18.25, 18.65) 22.52 (22.26, 22.79) 0.000
Fish (N/O) 74088 (65.77) 18.32 (18.20, 18.44) 16.69 (16.55, 16.83) 21.92 (21.69, 22.15) 0.000
Fish (D/W) 38551 (34.23) 19.25 (19.08, 19.42) 17.98 (17.77, 18.19) 21.41 (21.11, 21.70) 0.000
Chicken/meat(N/O) 73749 (65.47) 17.80 (17.68, 17.91) 16.40 (16.26, 16.53) 21.16 (20.94, 21.39) 0.000
Chicken/meat(D/W) 38891 (34.53) 20.44 (20.26, 20.62) 18.92 (18.69, 19.15) 22.60 (22.31, 22.89) 0.000
N/O never/occasional, D/W daily/weekly.

Dietary habits
In terms of diet, 20.44% women who consumed chicken/
meat daily or weekly, 20.01% women who consumed eggs
daily or weekly, and 19.25% women who consumed fish
daily or weekly had undiagnosed hypertension.
years old and adjusted OR 1.59 (95% CI, 1.54–1.65) for the
age group 45–49 years old. Comparatively in urban areas,
younger women at ages 20–39 were more at risk than
women at ages 40–49 years.
Smoking status, alcohol, and tobacco use

Multiple logistic regression analyses
Table 3 reports the unadjusted and adjusted odds ratio along
with 95% confidence interval for undiagnosed hypertension
in women aged 15–49 years.
Age
Age is a risk factor in multiple logistic regression model
with 40–44 years old, adjusted OR 1.20 (95% CI,
1.17–1.23) and 45–49 years old, adjusted OR 1.33 (95% CI,
1.30–1.37).
The multiple model denotes high risk for rural population
adjusted OR 1.40 (95% CI, 1.35–1.45) for age group 40–44
Women smokers possess higher risk, overall adjusted OR
1.13 (95% CI, 1.07–1.20), rural adjusted OR 1.12 (95% CI,
1.05–1.19) and urban adjusted OR 1.14 (95% CI,
1.00–1.31) compared to nonsmokers. Alcohol consumption
increased risk, overall adjusted OR 1.37 (95% CI,
1.29–1.45), rural adjusted OR 1.36 (95% CI, 1.28–1.45),
and urban adjusted OR 1.22 (95% CI, 1.08–1.39). Tobacco
users had a marginal risk compared to nontobacco users,
overall adjusted OR 1.06 (95% CI, 1.03–1.10).
Wealth index
Compared to those in the poorest wealth bracket, all other
quintiles including middle wealth quintile had adjusted OR
Prevalence and associated factors of undiagnosed hypertension among women aged 15–49 years in. . .

Fig. 2 Map of India showing statewise depiction of prevalence of undiagnosed hypertension among women aged 15–49 years in rural
India. The prevalence of undiagnosed hypertension in Rural India.

1.12 (95% CI, 1.10–1.15), richer wealth quintile
had adjusted OR 1.24 (95% CI, 1.21–1.27), and richest
wealth quintile had an adjusted OR 1.27 (95% CI,
1.23–1.30). Compared to those in the poorest
wealth quintile, the poorer were not significantly different in
the rural areas with adjusted OR 1.01 (95% CI, 0.98–1.03)
and urban areas adjusted OR 1.06 (95% CI, 0.98–1.15).
Educational attainment
Educational status also impacted risk as educational
attainment was a protective factor. Multiple logistic
regression model showed a slightly increased risk for col-
lege graduates in rural areas, adjusted OR 1.08 (95% CI,
1.04–1.12), but this factor was not significant in the urban
and overall analyses.
Caste and religion
Women who did not belong to caste/tribe were more sus-
ceptible to undiagnosed hypertension in rural areas, adjus-
ted OR 0.91 (95% CI 0.86–0.95), and among women who
did not know their caste in urban areas, adjusted OR 1.25
(95% CI, 1.11–1.40) compared to caste women. Christians
 D. Talukdar et al.

Fig. 3 Map of India showing statewise depiction of prevalence of undiagnosed hypertension among women aged 15–49 years in urban
India. The prevalence of undiagnosed hypertension in Urban India.

were more likely to have undiagnosed hypertension adjus-
ted OR 1.13 (95% CI, 1.08–1.18) than Hindus in both rural,
adjusted OR 1.13 (95% CI, 1.07–1.20) and urban, adjusted
OR 1.22 (95% CI, 1.05–1.20) areas.
BMI
Compared to normal BMI, all other categories were risk
factors for undiagnosed hypertension. Those who were
underweight (BMI < 18.5) were at risk, adjusted OR 1.43
(95% CI, 1.41–1.45), with those in urban areas being at
higher risk, adjusted OR 1.61 (95% CI, 1.56–1.66) and rural
areas at risk, adjusted OR 1.37 (95% CI, 1.34–1.40). They
were also at risk if in pre-obesity, obesity class I, obesity
class II, and obesity class III categories.
Geographical zones
Compared to those in northern zone, those in Western,
adjusted OR 1.45 (95% CI, 1.41–1.49) and Southern,
adjusted OR 1.33 (95% CI, 1.30–1.37) zones were at risk.
In urban areas, those in the Western zone were at greater
risk, adjusted OR 1.23 (95% CI, 1.18–1.28). In rural areas,
those in the Western zone, adjusted OR 1.57 (95% CI,
Table 3 Odds ratio and 95% confidence interval for undiagnosed hypertension in women (15–49 years).
Variables Unadjusted odds ratio (95% CI) Adjusted odds ratio (95% CI)
Overall Rural Urban Overall Rural Urban

Age, years
15–19 1 1 1 1 1 1
20–24 0.96 (0.94, 0.98)*** 1.02 (0.99, 1.04) 0.84 (0.81, 0.87)*** 0.96 (0.94, 0.98)*** 1.01 (0.99, 1.04) 0.88 (0.85, 0.92)***
25–29 0.93 (0.91, 0.95)*** 1.03 (1.00, 1.06) 0.75 (0.72, 0.77)*** 0.92 (0.90, 0.95)*** 1.02 (0.99, 1.05) 0.80 (0.77, 0.83)***
30–34 0.92 (0.89, 0.94)*** 1.04 (1.00, 1.07)* 0.71 (0.68, 0.74)*** 0.91 (0.89, 0.93)*** 1.03 (0.99, 1.06) 0.76 (0.73, 0.79)***
35–39 1.04 (1.02, 1.06)** 1.21 (1.18, 1.25)*** 0.76 (0.73, 0.79)*** 1.02 (0.99, 1.05) 1.19 (1.16, 1.23)*** 0.81 (0.77, 0.84)***
40–44 1.23 (1.20, 1.26)*** 1.42 (1.38, 1.46)*** 0.91 (0.88, 0.95)*** 1.20 (1.17, 1.23)*** 1.40 (1.35, 1.45)*** 0.97 (0.93, 1.01)
45–49 1.37 (1.34, 1.41)*** 1.63 (1.58, 1.68)*** 0.98 (0.94, 1.02) 1.33 (1.30, 1.37)*** 1.59 (1.54, 1.65)*** 1.04 (0.99, 1.09)
Current smoking status
Nonsmoker 1 1 1 1 1 1
Smoker 1.10 (1.04, 1.17)** 1.17 (1.10, 1.24)*** 1.13 (1.00, 1.29)*** 1.13 (1.07, 1.20)*** 1.12 (1.05, 1.19)** 1.14 (1.00, 1.31)*
Current alcohol use
Nonalcoholic 1 1 1 1 1 1
Alcoholic 1.45 (1.37, 1.53)*** 1.57 (1.48, 1.67)*** 1.32 (1.17, 1.49)*** 1.37 (1.29, 1.45)*** 1.36 (1.28, 1.45)*** 1.22 (1.08, 1.39)**
Current tobacco use
Nontobacco user 1 1 1 1 1 1
Tobacco user 1.08 (1.04, 1.11)*** 1.14 (1.10, 1.18)*** 1.03 (0.97, 1.09)*** 1.06 (1.03, 1.10)*** 1.04 (1.00, 1.08)* 1.07 (1.01, 1.14)*
Wealth
Poorest 1 1 1 1 1 1
Poorer 1.08 (1.05, 1.10)*** 1.06 (1.03, 1.08)*** 1.10 (1.02, 1.19) 1.03 (1.01, 1.05)** 1.01 (0.98, 1.03) 1.06 (0.98, 1.15)
Middle 1.23 (1.20, 1.25)*** 1.16 (1.14, 1.19)*** 1.21 (1.13, 1.30)*** 1.12 (1.10, 1.15)*** 1.05 (1.02, 1.08)** 1.12 (1.04, 1.21)**
Richer 1.37 (1.35, 1.40)*** 1.25 (1.22, 1.28)*** 1.26 (1.18, 1.35)*** 1.24 (1.21, 1.27)*** 1.10 (1.07, 1.14)*** 1.18 (1.10, 1.27)***
Prevalence and associated factors of undiagnosed hypertension among women aged 15–49 years in. . .

Richest 1.39 (1.36, 1.42)*** 1.17 (1.13, 1.21)*** 1.23 (1.15, 1.31)*** 1.27 (1.23, 1.30)*** 1.08 (1.03, 1.12)*** 1.16 (1.07, 1.25)***
Education
No education 1 1 1 1 1 1
Primary 0.98 (0.96, 1.01) 0.94 (0.91, 0.96)*** 1.02 (0.98, 1.07) 0.97 (0.95, 0.99)** 0.98 (0.95, 1.00) 0.99 (0.95, 1.04)
Secondary 1.02 (1.01, 1.04)** 0.94 (0.92, 0.95)*** 1.05 (1.02, 1.08)*** 0.97 (0.95, 0.98)*** 1.01 (0.98, 1.03) 0.97 (0.94, 1.01)
Higher 1.09 (1.07, 1.12)*** 0.99 (0.96, 1.03) 0.99 (0.95, 1.02) 1.00 (0.97, 1.03) 1.08 (1.04, 1.12)*** 0.97 (0.93, 1.02)
Social caste
Caste 1 1 1 1 1 1
Tribe 0.98 (0.96, 1.01) 1.05 (1.02, 1.08)** 1.03 (0.97, 1.10) 0.99 (0.96, 1.02) 1.01 (0.98, 1.05) 1.00 (0.93, 1.06)
No caste/tribe 0.92 (0.89, 0.95)*** 0.92 (0.88, 0.97)** 0.89 (0.84, 0.94)*** 0.91 (0.87, 0.94)*** 0.91 (0.86, 0.95)*** 0.93 (0.88, 0.98)*
Do not know 1.01 (0.93, 1.09) 0.93 (0.83, 1.03) 1.05 (0.93, 1.17) 1.11 (1.03, 1.21)* 0.98 (0.87, 1.09) 1.25 (1.11, 1.40)***
Table 3 (continued)
Variables Unadjusted odds ratio (95% CI) Adjusted odds ratio (95% CI)
Overall Rural Urban Overall Rural Urban

Religion
Hindu 1 1 1 1 1 1
Muslim 1.01 (0.99, 1.02) 0.96 (0.94, 0.99)** 0.96 (0.94, 0.99)** 1.02 (1.00, 1.04) 1.02 (0.99, 1.05) 0.96 (0.93, 0.99)**
Christian 1.32 (1.27, 1.38)*** 1.37 (1.30, 1.45)*** 1.19 (1.12, 1.27)*** 1.13 (1.08, 1.18)*** 1.13 (1.07, 1.20)*** 1.22 (1.05, 1.20)***
Others/not stated 1.06 (1.03, 1.10)** 1.07 (1.02, 1.12)** 1.01 (0.95, 1.07) 1.02 (0.98, 1.06) 1.13 (1.08, 1.19)*** 0.93 (0.87, 0.98)*
BMI
Normal (18.5–24.9) 1 1 1 1 1 1
Underweight (<18.5) 1.36 (1.34, 1.38)*** 1.31 (1.29, 1.34)*** 1.64 (1.60, 1.69)*** 1.43 (1.41, 1.45)*** 1.37 (1.34, 1.40)*** 1.61 (1.56, 1.66)***
Pre-obesity (25–29.9) 1.29 (1.27, 1.31)*** 1.40 (1.36, 1.43)*** 1.08 (1.05, 1.11)*** 1.14 (1.11, 1.16)*** 1.23 (1.20, 1.27)*** 1.05 (1.02, 1.09)***
Obesity Class I 1.68 (1.63, 1.74)*** 1.90 (1.81, 2.00)*** 1.35 (1.30, 1.42)*** 1.40 (1.35, 1.45)*** 1.62 (1.53, 1.70)*** 1.29 (1.23, 1.35)***
(30–34.9)
Obesity Class II 1.88 (1.76, 2.01)*** 2.00 (1.78, 2.25)*** 1.57 (1.44, 1.71)*** 1.52 (1.42, 1.63)*** 1.68 (1.49, 1.89)*** 1.47 (1.35, 1.60)***
(35–39.9)
Obesity Class III 1.79 (1.61, 1.99)*** 1.53 (1.31, 1.79)*** 1.86 (1.61, 2.15)*** 1.60 (1.44, 1.78)*** 1.44 (1.23, 1.69)*** 1.75 (1.52, 2.02)***
(≥40)
Zones
Northern 1 1 1 1 1 1
Central 0.88 (0.86, 0.90)*** 1.02 (1.00, 1.06) 0.76 (0.74, 0.79)*** 0.91 (0.88, 0.93)*** 1.04 (1.01, 1.08)* 0.74 (0.71, 0.77)***
Eastern 0.95 (0.92, 0.97)*** 1.13 (1.10, 1.17)*** 0.78 (0.75, 0.81)*** 1.00 (0.97, 1.03) 1.16 (1.12, 1.20)*** 0.77 (0.73, 0.81)***
Western 1.50 (1.46, 1.53)*** 1.62 (1.56, 1.67)*** 1.26 (1.22, 1.31)*** 1.45 (1.41, 1.49)*** 1.57 (1.52, 1.63)*** 1.23 (1.18, 1.28)***
Southern 1.41 (1.38, 1.45)*** 1.70 (1.65, 1.75)*** 1.08 (1.04, 1.12)*** 1.33 (1.30, 1.37)*** 1.59 (1.54, 1.65)*** 1.04 (1.00, 1.08)*
North-Eastern 1.12 (1.08, 1.17)*** 1.35 (1.29, 1.41)*** 0.94 (0.87, 1.02) 1.14 (1.09, 1.19)*** 1.32 (1.25, 1.39)*** 0.90 (0.82, 0.98)*
Diet
Milk/curd (N/O) 1 1 1 1 1 1
Milk/curd (D/W) 1.06 (1.05, 1.08)*** 1.01 (1.00, 1.03) 1.05 (1.03, 1.08)*** 0.94 (0.93, 0.96)*** 0.95 (0.93, 0.97)*** 0.96 (0.94, 0.99)*
Pulse/beans (N/O) 1 1 1 1 1 1
Pulse/beans (D/W) 1.01 (0.99, 1.04) 1.00 (0.97, 1.02) 0.99 (0.95, 1.03) 1.00 (0.98, 1.03) 0.99 (0.97, 1.02) 1.02 (0.98, 1.07)
Vegetables (N/O) 1 1 1 1 1 1
Vegetables (D/W) 1.02 (1.00, 1.04)* 1.00 (0.98, 1.02) 1.02 (0.99, 1.05) 0.98 (0.96, 1.00) 0.97 (0.94, 0.99)** 1.00 (0.96, 1.03)
Fruits (N/O) 1 1 1 1 1 1
Fruits (D/W) 1.15 (1.14, 1.17)*** 1.10 (1.08, 1.12)*** 1.04 (1.02, 1.06)*** 1.03 (1.01, 1.04)** 1.02 (0.99, 1.04) 1.00 (0.98, 1.03)
Eggs (N/O) 1 1 1 1 1 1
Eggs (D/W) 1.16 (1.15, 1.18)*** 1.16 (1.14, 1.18)*** 1.09 (1.07, 1.11)*** 1.09 (1.07, 1.11)*** 1.05 (1.03, 1.07)*** 1.11 (1.08, 1.14)***
Fish (N/O) 1 1 1 1 1 1
D. Talukdar et al.
Prevalence and associated factors of undiagnosed hypertension among women aged 15–49 years in. . .

1.52–1.63), southern zone adjusted OR 1.59 (95% CI,

0.88 (0.86, 0.91)***

1.08 (1.05, 1.11)***

1.54–1.69), and north-eastern zone adjusted OR 1.32 (95%
CI, 1.25–1.39) were at greater risk.
Urban

Dietary habits
1
Among dietary eating patterns, those consuming milk/curd
on a daily/weekly basis were less likely, adjusted OR 0.94
0.95 (0.93, 0.97)***

1.06 (1.04, 1.09)***

(95% CI, 0.93–0.96) to have undiagnosed hypertension than

those who never/occasionally consumed them. Those con-
suming fish on a daily/weekly basis were less likely,
adjusted OR 0.92 (95% CI, 0.90–0.94) to have undiagnosed
Rural

hypertension compared to those who never/occasionally

consume fish. Eating vegetables on a daily/weekly basis
Adjusted odds ratio (95% CI)

was also a protective factor, especially in the rural areas,

adjusted OR 0.97 (95% CI, 0.94–0.99).
0.92 (0.90, 0.94)***

1.07 (1.06, 1.10)***

Discussion
Overall

Our study reported the prevalence of undiagnosed hyper-

1

tension among women aged 15–49 years to be 18.63% with

the prevalence at 17.09% in rural areas and 21.73% in urban
areas. Though no other study based upon the NFHS-4 data
1.09 (1.06, 1.11)***
0.97 (0.95, 1.00)**

focuses on undiagnosed hypertension in India, we do have

reportage of known hypertension which is 11.3% as
reported by the NFHS-4 [13]. Most other studies combine
the data of measured BP with some other self-reported
Urban

answers to questions pertaining to medication for hyper-

1

tension. Corsi and Subramanian use combined BP measured

data of women aged 15–49 years, men aged 15–54 years
and include those on medication to report 14.4% prevalence
1.09 (1.08, 1.11)***

1.19 (1.17, 1.21)***

of hypertension [22]. A study by Prenissl et al. on the same

data estimated an overall prevalence of hypertension to be
18.1%. The higher prevalence rate was based upon a
combination of BP measurements and answers to two
Rural
Unadjusted odds ratio (95% CI)

questions on awareness and medication. They found that the

1

prevalence of hypertension was higher among men (19%)

than women (17.2%) [5]. In another nationally representa-
1.06 (1.05, 1.08)***

1.19 (1.17, 1.20)***

tive survey study conducted in India, Geldsetzer et al. found

the prevalence of hypertension to be 25.3% [23]. A third
nationally representative survey study estimated the overall
N/O never/occasional, D/W daily/weekly.

prevalence of hypertension to be 30.7% but a low level of

Overall

*p < 0.05; **p < 0.01; ***p < 0.001.

self-reported hypertension of 15.9% among adult popula-

tion in India [24]. A systematic review conducted by
1

Anchala et al. [6] estimated the overall prevalence of

hypertension at 29.8% in the Indian population. They
Chicken/meat (D/W)
Chicken/meat (N/O)

estimated that 27.6% were residing in rural areas while

Table 3 (continued)

33.8% resided in urban areas. Swain et al. used estimates of

25% in urban and 10% in rural India [8]. The differences in
Fish (D/W)

figures are primarily due to methodological differences in

Variables

selecting population and defining hypertension. Our study

reports the self-reported hypertension at 8.86% (Fig. 1).

This in no way overlaps with the women who did not report
being hypertensive yet could be categorized as hypertensive
based solely upon the data of their measured BP. This was
defined as “undiagnosed hypertension” in our analyses and
its prevalence was 18.63%. A second methodological dif-
ference from other studies is that we applied thresholds of
70–270 mmHg for systolic readings and 40–140 mmHg for
diastolic readings in defining hypertension. This enabled us
to reject improbable values.
Several smaller cross-sectional studies have reported
varying prevalence rates for reported and unreported pre-
valence of hypertension. Chakraborty and Mandal [9] found
the prevalence of hypertension to be 24.1% in a rural area in
West Bengal in India while Undavalli et al. found pre-
valence of undiagnosed hypertension at 10.1% in villages in
a rural area in India [25]. Shukla et al. [26] found the pre-
valence of undiagnosed hypertension to be 26% in an
apparently healthy population in Western India. Singh et al.
found an overall prevalence of 32.96% in urban Varanasi in
Uttar Pradesh in India [27] while a study by Banerjee et al.
found hypertension prevalence at 42% with newly detected
cases at 19% in a study conducted in a slum population in
urban Kolkata in West Bengal in India [28]. The wide
variations in prevalence rates point to methodological dif-
ferences as well as large regional, geographical, cultural,
and social factors that determine prevalence rates.
Our study found that the prevalence of undiagnosed
hypertension was higher among women in urban India than
in rural India. This could be related to higher awareness and
better health facilities in urban areas than rural areas, or it
could be attributable to diet and stress-related issues as
suggested by Swain et al. [8]. However, this tends to
hypothesize that the rural population are poor, less educated
and in lower wealth quintiles. Some regional epidemiolo-
gical studies have found an urban–rural convergence in
hypertension prevalence [29, 30]. Gupta [29] suggests that
this urban–rural convergence of hypertension in India is due
to rapid urbanization of rural populations with consequent
changes in lifestyles (sedentariness, high dietary salt, sugar,
and fat intake) and increase in overweight and obesity.
Nevertheless, our study found the prevalence of undiag-
nosed hypertension was 17.09% in rural areas and it was
21.73% in urban areas.
Our multiple logistic regression suggests that an increase
in age leads to an increase in the probability of undiagnosed
hypertension. This was even more visible in the rural areas
than in the urban areas since age became a risk factor in
rural areas from ages 35 and above while ages 40 and less
were a protective factor in urban areas. It shows poor
general awareness and screening opportunities among
women in the rural areas regarding their health concerns in
higher age groups and conversely for lower age groups in
urban areas. It is to be noted that undiagnosed hypertension
D. Talukdar et al.
is a point of concern even among younger age groups, those
under 30 years of age, which is consistent with other studies
[22, 23]. These cases could also be related to oral contra-
ceptive pills induced hypertension since it is suggested that
BP rises after menopause in most women due to withdrawal
of endogenous estrogen, a potent vasodilator [10, 31, 32].
Undiagnosed hypertension could have unforeseen con-
sequences for maternal and child care programs since
hypertension during pregnancy leads to complications in
both mother and child.
Corsi and Subramanian found that increase in wealth led
to an increase in hypertension from 11 to 17.1% [22]. Our
study also found that an increase in wealth led to an increase
in the prevalence of undiagnosed hypertension across both
rural and urban areas. Hypertension tends to be inversely
related to socioeconomic position in high income countries
[33] with the opposite being the case in low- and middle-
income countries [34]. However, being in poorest or richest
wealth quintile alone cannot be responsible for high rates of
undiagnosed hypertension in India because low levels of
awareness and poor access to health facilities [26] are
restricted to those belonging to the poorest wealth quintiles
in both rural and urban areas.
Those women who did not know their caste or did not
reveal their caste were more likely to have undiagnosed
hypertension than those who knew/disclosed their caste.
Women who followed the Christian faith were more likely
to have undiagnosed hypertension than those women who
followed the Hindu faith. Though any discussion of dif-
ferences only due to caste and religion is insensitive to their
position in local social hierarchies, it could be conjectured
that caste and religion do play a role in their choice of diets
and lifestyles.
Compared to those with normal BMI, women who were
in underweight and pre-obesity, obesity classes I–III, were
more prone to suffer from undiagnosed hypertension. An
important finding is that lower BMI is a risk factor that has
not received much attention in previous studies. A study on
African and Asian populations had also found extremely
low or high BMI levels to be associated with increased risk
of hypertension [35]. Another study had found BMI under
18.5 kg/m2 to be a risk factor for CVD [36]. The effect of
BMI increase was more pronounced among those living in
rural areas than in urban areas for those women who were
classed under pre-obesity, obesity class I, and obesity class
II categories. This suggests that in general more women
with increased BMI in the rural areas have undiagnosed
hypertension than those in urban areas. Most studies com-
pare BMIs higher than normal with normal BMI. Shihab
et al. [37] found that the rate of change in BMI over the life
course increased the risk of incident hypertension. Basu and
Millett reported that obesity increased the probability of
hypertension by 3.7 times [38]. They found ≥10%
Prevalence and associated factors of undiagnosed hypertension among women aged 15–49 years in. . .
prevalence of obesity even among the lowest income
quintiles. Obesity is a known risk factor for hypertension
[39, 40] though Swain et al. did not find hypertension
related to obesity among women [8].
Women living in the Western zone in the urban areas
were more likely to suffer from undiagnosed hypertension
than those living in the northern zone. Women living in
rural areas in the Western, Southern and North-Eastern
zones were more likely to have undiagnosed hypertension
than those in the northern zone. This is a significant finding
as it may be related to lack of information, education, or
communication among women living in these zones.
Anchala et al. [6] found the pooled prevalence of hyper-
tension for the rural and urban population in North India to
be 14.5% and 28.8%. The corresponding figures for East
India were 31.7% and 34.5%, for West India 18.1% and
35.8%, and for South India 21.1% and 31.8%. The defini-
tion for the four zones was different from the NFHS defined
six zones in India. Gelsetzer et al. [23] found prevalence of
hypertension to be highest in the northern states of Punjab
and Himachal Pradesh, the southern state of Kerala, and the
north-eastern states of Sikkim, and Nagaland. They had no
data available for Jammu and Kashmir and Gujarat. A
WHO-STEPS cross-sectional survey in Punjab found an
overall prevalence of 40.1% with 28.7% of cases being
newly diagnosed in rural areas and 27.2% being newly
diagnosed in urban areas [39]. Our study found that
undiagnosed hypertension was highest in the state of Tel-
angana in both rural and urban areas.
Women eating eggs, and/or chicken/meat on a daily/
weekly basis were more likely to suffer from undiagnosed
hypertension than those women who never/occasionally eat
these items. Eating vegetables was a protective factor. This
is in line with other studies that found a vegetable diet to be
a protective factor in hypertension [26] and recommend a
diet rich in fruits, vegetables and low-fat dairy products in
all stages of high BP management [41, 42].
Smoking status, tobacco, and alcohol consumption had
minimal effects on the prevalence of undiagnosed hyper-
tension among women aged 15–49 years.
Conclusion
The risk factors for undiagnosed hypertension do not vary
from risk factors associated with those with known hyper-
tension. Increase in age, wealth and BMI were risk factors
while an increase in education and eating vegetables were
protective factors. Our study highlights a large proportion of
young women and women with lower than normal BMI
(<18.5) suffering from undiagnosed hypertension. It is a
matter of great importance that almost one in five women
aged 15–49 years is unaware of being hypertensive and are
not being treated. Since these women are in the reproductive
age, elevated BP levels could have detrimental effects on
women and their unborn children. Undiagnosed, hence
untreated and uncontrolled, BP could have health con-
sequences in the short term and long term. We recommend
regular screenings for early detection and treatment of
hypertension in a bid to reduce NCDs incidence in India.
Limitations
This study has various limitations. It is based upon sec-
ondary data available from a cross-sectional NFHS survey
that assesses relationships at one point in time. In addition,
there is a recall bias and low truth quotient associated with
all survey instruments. Our particular study may also suffer
from a misclassification bias since we clubbed together
missing observations with NO self-reported hypertension.
We relied on BP measurements to detect undiagnosed
hypertension. However, measurements made on a single
occasion do not have a strong predictive power for CVD in
epidemiological studies [30]. Further, if we applied the
AHA new thresholds of 130/80 for stage 1 hypertension, the
number of people with undiagnosed hypertension would be
substantially more. Lastly, the survey population was
restricted to women aged 15–49 years. It is known that
hypertension affects greatly those aged above 50 years.
Summary
What is known about topic
● Raised blood pressure causes 7.5 million deaths
annually.
● Factors associated with hypertension include age, higher
BMI, poor access to health facilities, rural area of
residence and irregular lifestyles.
What this study adds
● Our study focuses on undiagnosed hypertension among
women in the reproductive age group, 15–49 years.
● Almost one in five women aged 15–49 years in India has
undiagnosed hypertension.
● Prevalence of undiagnosed hypertension was 17.09% in
rural areas compared with 21.73% in urban areas.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.

Ethical approval We obtained permission from the United States
Agency for International Development-supported Demographic and
Health Survey Program at ICF to access individual records from the
Demographic and Health Survey (DHS) site. India’s Ministry of
Health and Family Welfare and the ICF institutional review board
approved the 2015–2016 NFHS survey protocol [13]. Our study uses
secondary data and thus is exempted from requirements of obtaining
ethical approvals.
Publisher’s note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
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